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12th Annual International Congress on the Future of Breast Cancer®

12th Annual International Congress on the Future of Breast Cancer®


Resources

12th Annual International Congress on the Future of Breast Cancer®: Meeting-in-a-Box
The Meeting-in-a-Box components are designed for you to share the information with colleagues, fellows, and other health care professionals.

PER Pulse™ Recap
Three PER Pulse™ Recaps presenting key topics from the 12th Annual International Congress on the Future of Breast Cancer®, which was held on July 18 - 20, 2013.



PER Meeting in a Box


Presentation Title Faculty Discussion Question
Is It Stage or Is It Biology? Kathy S. Albain, MD, FACP Which is more important in deciding whether a patient with ER+, node-negative breast cancer should receive adjuvant chemotherapy – standard clinico-pathologic criteria (eg, tumor size, grade) or biology? What about in node-positive disease? Do multigene assays have any utility in this setting?
Duration of Adjuvant Endocrine Therapy: What Have ATLAS and aTTom Taught Us? Christy A. Russell, MD Is 10 years of tamoxifen the new standard in adjuvant endocrine therapy for premenopausal women with ER+ breast cancer? If not, which patients should receive 5 years versus 10 years of therapy? Should data from the ATLAS and aTTom trials be extrapolated to aromatase inhibitors in postmenopausal patients?
ER+ BC Controversies, Lobular Breast Cancers, Therapeutic Considerations Joseph Sparano, MD What form of adjuvant endocrine therapy do you generally choose for a postmenopausal patient with a lobular histology? Do the data from the BIG 1-98 subset analysis influence your opinion on using aromatase inhibitors in these patients?
Who Benefits From PI3K/mTOR Blockade? Hope S. Rugo, MD In which patients with ER+ metastatic breast cancer (MBC) do you use everolimus plus exemestane? What side effects do you most commonly encounter with this regimen, and what management strategies do you employ?
Altered Fractionation: When Is It Appropriate? Jennifer R. Bellon, MD How do hypofractionation results compare with those from conventional radiation therapy schedules with regard to efficacy? Toxicity? Cosmesis?

Which patients are suitable for accelerated partial-breast irradiation? Which patients should not be treated with this approach?
Coordinating Radiation and Reconstruction Alice Ho, MD  
Sentinel Lymph Node Biopsy and Neoadjuvant Therapy Eleftherios Mamounas, MD, MPH, FACS For a patient with cN1 disease who is going to receive neoadjuvant chemotherapy, would you recommend sentinel lymph node biopsy before or after systemic therapy?
Is Systemic Therapy Effective After Locoregional Recurrence? Irene L. Wapnir, MD Do you offer chemotherapy to patients with previously treated ER- breast cancer who experience an ipsilateral local and/or regional recurrence? Have the CALOR results influenced your practice?
The New Guidelines for MBC Manangement Hope Rugo, MD  
Adjuvant and Neoadjuvant HER2-Targeted Therapy: Best Practices  Debu Tripathy, MD What is the most appropriate duration of adjuvant trastuzumab therapy? Are there any situations where you would consider longer or shorter courses of therapy?

Do you ever recommend adjuvant trastuzumab for a patient with a T1a/b N0 HER2+ tumor? What factors influence your decision?
Data-Driven Management of HER2+ MBC Joyce O'Shaughnessy, MD What first-line chemotherapy/HER2-targeted therapy combination do you recommend most frequently for your patients with HER2+ MBC? Do the overall survival results from the CLEOPATRA trial influence your decision on whether to use the triplet combination with pertuzumab? Do you believe there are sufficient data to support the substitution of paclitaxel for docetaxel? Is this regimen suitable for older patients?

What treatment do you typically recommend for a patient with HER2+ MBC that has progressed on trastuzumab and a taxane? What are the pros and cons of different options for relapsed/refractory disease?
The Role of HER1 and HER3 in HER2+ Breast Cancer Brent Rexer, MD, PhD  
HER2-Targeted Vaccine Therapies Elizabeth Mittendorf, MD, PhD  
Ki67: The Good, the Bad, and the Clinical Utility Torsten O. Nielsen, MD, PhD, FRCPC  
Lessons from The Cancer Genome Atlas for ER+ Breast Cancer Matthew Ellis, M.B., B.Chir., Ph.D.  
Optimizing Non-Anthracycline Adjuvant Therapy Stephen E. Jones, MD Which do you recommend most often for patients requiring adjuvant chemotherapy, an anthracycline- or non-anthracycline-based regimen? What factors are most important when making this decision with an individual patient? In which clinical situations would you use an anthracycline-based regimen? A non-anthracycline-based regimen? Does HER2 status influence your choice?
Osteoclast-Targeted Therapy, Forever? Frankie Ann Holmes, MD, FACP When do you typically initiate anti-osteoclast therapy in a patient with MBC – upon documented evidence of bone disease, or only when bone disease becomes symptomatic? When using a bisphosphonate in this setting, what schedule do you use? Do you ever reduce the frequency of administration?

When would you recommend anti-osteoclast therapy for the prevention of bone loss in a postmenopausal patient who is starting therapy with an aromatase inhibitor? Do you use a certain bone mineral density cutoff, and if so, what is the trigger point for you? Do you ever use online tools to estimate fracture risk?

What do you do to minimize the risk of adverse events (such as osteonecrosis of the jaw) in your patients who will be receiving anti-osteoclast therapy?
Washington Update - Examining the Oncology Landscape Post-Healthcare Reform Ben Jones  
When to Consider Platinum-Based Therapy Melinda L. Telli, MD Do you use platinum-based chemotherapy for patients with triple-negative or BRCA1/2-mutated MBC? If so, at what point in disease progression (ie, earlier or later)? Do you ever recommend including a platinum agent for early-stage breast cancers?
Novel Preoperative Strategies for TNBC Ingrid A. Mayer, MD, MSCI  
Novel Therapies for Brain Metastases Carey Anders, MD Do you recommend upfront whole-brain radiation therapy to your patients who are candidates for stereotactic radiosurgery? How important is recurrence risk versus the risk of neurocognitive decline?
Therapeutic Advances in TNBC Joyce A. O'Shaughnessy, MD Which agent would you typically use first in a patient with TNBC that has progressed on anthracyclines and taxanes – capecitabine or eribulin? Does order matter?
Targeting the Metastatic Machinery Lori J. Goldstein, MD  
NCI-FDA Efforts to Accelerate Availability of Novel Agents Jo Anne Zujewski, MD  
Is There Clinical Utility in Genomic Profiling of MBCs? Stefan Gluck, MD, PhD, FRCPC Do you believe that precision medicine (using next-generation sequencing to identify mutations and select targeted therapies) is ready for prime time in MBC?

Have you, or would you, order this type of molecular profile to identify possible therapeutic options? To identify potential clinical trial options?
Environmental Breast Carcinogenesis David Euhus, MD  
SCOTUS Patent Decision and the Future of Genetic Testing Ellen Matloff, MS  





PER Pulse™ Recap

PER Pulse™ Recap:
Medical Writer: Susan R. Peck, PhD



1 of 3   PER Pulse™ Recap
12th Annual International Congress on the Future of Breast Cancer®
Controversies in the Management of Hormone Receptor-Positive Breast Cancer 

The 12th Annual International Congress on the Future of Breast Cancer®, held July 18-20, 2013, in Huntington Beach, CA, brought together an expert faculty to review the latest data on local and systemic therapies for breast cancer; to discuss and debate controversies, clinical implications, and applications to real-world patient scenarios; and to preview promising investigational agents and approaches that could impact patient care in the future. This is the first of 3 PER Pulse™ Recaps which will review highlights from this meeting; this recap will focus on a session devoted to managing hormone receptor (HR)-positive breast cancer.
  • Dr. Kathy Albain began the session on HR-positive breast cancer with a discussion of whether stage or biology was more important in determining the need for adjuvant chemotherapy. She noted that clinical criteria alone may lead to under- or overtreatment of a substantial number of patients. Biology matters even in “low-risk” breast cancer, while in “high-risk” breast cancer, molecular signatures may differentiate degree of sensitivity to chemotherapy.
     
  • Dr. Christy Russell reviewed data from the ATLAS and aTTom trials, which both showed a long-term survival benefit with 10 years of adjuvant tamoxifen compared with 5 years. For premenopausal patients with HR-positive breast cancer, 10 years of tamoxifen is now a reasonable option; the decision should be individualized based on absolute risk of recurrence and potential benefit of therapy.
     
  • Dr. Joseph Sparano summarized data from a subset analysis of the BIG 1-98 trial showing that lobular cancers derived greater magnitude of benefit from adjuvant letrozole versus tamoxifen compared with ductal cancers, while luminal B cancers derived more benefit than luminal A cancers.
     
  • Dr. Hope Rugo discussed the rationale and growing clinical role for PI3K/mTOR blockade in overcoming resistance to endocrine therapies, noting that the combination of endocrine agents and mTOR inhibitors represents a new paradigm in therapy for HR-positive metastatic breast cancer. This remains an active area of investigation, with ongoing trials combining endocrine therapies with mTOR- and/or PI3K-targeted agents in both metastatic and early-stage settings.
     
  • Finally, several lectures focused on emerging investigational agents and promising preclinical research. Dr. Richard Finn covered two important classes of agents currently in later-phase clinical trials, including a number of novel PI3K inhibitors, as well as palbociclib, a CDK 4/6 inhibitor. Studies integrating these novel biologics with endocrine therapies to overcome resistance are showing promise. Dr. Suzanne Fuqua summarized preclinical research exploring the role of the androgen receptor (AR) in breast cancer, although she emphasized that there is not enough clinical evidence yet to routinely use AR-targeted agents in AR-positive breast cancer, and clinical trials are ongoing. Dr. Carol Lange reviewed recent research into the role of progesterone receptor expression in breast cancer cells.



2 of 3   PER Pulse™ Recap
12th Annual International Congress on the Future of Breast Cancer®
Controversies in Managing HER2+ Breast Cancer

The 12th Annual International Congress on the Future of Breast Cancer®, held July 18-20, 2013, in Huntington Beach, CA, brought together an expert faculty to review the latest data on local and systemic therapies for breast cancer; to discuss controversies, clinical implications and applications to real-world patient scenarios; and to preview promising investigational agents and approaches that could impact patient care in the future. This is the second of 3 PER Pulse™ Recaps, which will review highlights from this meeting; this recap will focus on the session devoted to managing HER2+ breast cancer.
  • Dr. Debu Tripathy reviewed current areas of consensus or controversy in the use of HER2-targeted adjuvant therapies. Adding trastuzumab to (neo)adjuvant therapy for HER2+ breast cancer has significantly reduced recurrence and mortality, and 1 year has now been firmly established as the optimal duration of therapy. Although the overall incidence of cardiotoxicity is low, it is a real risk, particularly in certain patient subsets (age ≥ 50, left ventricular ejection fraction [LVEF] 50-54), and cardiac function needs to be monitored regularly. Finally, some T1a/b N0 HER2+ cancers benefit from adding trastuzumab to adjuvant chemotherapy. Better tools are needed for predicting both benefit and cardiac toxicity, and in the future, individualized, rational combinatorial therapy will be the norm.
     
  • Dr. Joyce O’Shaughnessy summarized the current landscape of therapies for HER2+metastatic breast cancer (MBC). Pertuzumab in combination with trastuzumab and a taxane is now the optimal first-line standard of care for these patients, based on the survival advantage in the CLEOPATRA trial. For patients with recurrent, pretreated HER2+ MBC, ado-trastuzumab emtansine (T-DM1) has now been shown to improve overall survival as well as progression-free survival (PFS) compared with lapatinib/capecitabine. Everolimus has also been shown to improve PFS when added to vinorelbine plus trastuzumab. Both of these agents are now being explored in first-line regimens, and results from these trials may further alter the treatment algorithm for HER2+ MBC.
     
  • Dr. Elizabeth Mittendorf provided an overview of investigational strategies involving HER2-derived peptide vaccines. Cancer vaccines represent a nontoxic therapeutic modality with a high level of specificity. Early studies have demonstrated promising activity in the adjuvant, minimal disease setting, and a phase III trial is currently investigating the E75 vaccine in 700 patients with node-positive, early-stage breast cancer with low-to-intermediate HER2 expression. Current challenges to vaccine development include identifying the correct patients and determining immune responses that correlate with clinical efficacy.
     
  • Dr. Brent Rexer provided a glimpse inside the cell, with a lecture on preclinical investigation into the roles of the HER1 and HER3 receptors in HER2+ breast cancer. The formation of HER2/HER3 dimers and signaling through HER3 plays a critical role in the growth and survival of HER2+ tumor cells, while HER1 (EGFR) expression may play a role in resistance to HER2-targeted therapies. While combinations of HER2-targeted agents have demonstrated efficacy, the current questions are:  Which combinations or sequences are the most effective, and for which patients?



3 of 3   PER Pulse™ Recap
12th Annual International Congress on the Future of Breast Cancer®
Practical Updates for Monday Morning
 
The 12th Annual International Congress on the Future of Breast Cancer®, held July 18-20, 2013, in Huntington Beach, CA, brought together an expert faculty to review the latest data on local and systemic therapies for breast cancer, to discuss controversies, clinical implications and applications to real-world patient scenarios, and  to preview promising investigational agents and approaches that may impact patient care in the future. This is the third of 3 PER Pulse™ Recaps that will review highlights from this meeting; this recap will focus on the session devoted to practical patient management issues.
  • Dr. Stephen Jones discussed the role of nonanthracycline-based regimens as adjuvant therapy for early-stage breast cancer. He reminded the audience that although the Oxford meta-analysis confirmed a benefit for anthracyclines, this benefit appears to be restricted to the HER2+ subset. Further, anthracyclines are associated with significant cardiac toxicity, which may appear much later, as well as a rare but real risk of developing secondary leukemias or myelodysplastic syndrome. The USON 9735 and BCIRG 006 trials support the use of docetaxel/cyclophosphamide (TC) or docetaxel/carboplatin/trastuzumab (TCH) in HER2-negative or HER2-positive breast cancers, respectively. Results of these studies have led to a decrease in the usage of anthracycline-based regimens worldwide; however, clinicians need to be cognizant of the increased rates of febrile neutropenia and consider the use of growth factor support when using the docetaxel-based regimens. One remaining question concerns how the TC regimen compares with more modern anthracycline- and taxane-based regimens, and the ongoing NSABP B-49 trial will address this issue by comparing 6 cycles of TC versus several other standard anthracycline/taxane regimens.
  • Dr. Frankie Ann Holmes discussed practical issues regarding the use of osteoclast-directed therapies, such as bisphosphonates or RANKL-targeted antibodies. All patients should be sent for a dental evaluation and be cleared for anti-osteoclast therapy before initiating treatment with these agents to reduce the risk of osteonecrosis of the jaw. For patients with metastatic breast cancer, anti-osteoclast therapy should be initiated at the first documentation of bone disease, even if asymptomatic. The optimal duration and scheduling of anti-osteoclast therapy has not been determined by randomized trials, and guideline recommendations differ between organizations. Thus, these decisions need to be individualized, taking into consideration risk of skeletal-related events versus potential side effects. For patients with early-stage breast cancer receiving adjuvant aromatase inhibitors, bone mineral density should be evaluated within the first year. Calculating the FRAX score using the online WHO Fracture Risk Assessment tool (www.shef.ac.uk/FRAX) can aid in making treatment decisions. Duration of therapy is uncertain in this setting also, and most experts recommend reassessment and individualization after 3-5 years of therapy.



For additional commentary about these topics and others, visit www.gotoper.com for downloadable PDF slides from this meeting, as well as other breast cancer-focused CME activities.

Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is not approved for AMA PRA Category 1 Credit™.

Supported by educational grants from Celgene Corporation, Eisai Inc., Genentech, Lilly USA, LLC, and Novartis Pharmaceuticals Corporation. 







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